The College of Saint Rose/Teacher Education Institute (TEI)

APPLICATION :

____________________________________________________________

Office of Graduate and Continuing Education Admissions 432 Western Avenue, Albany, NY 12203
(518) 454-5143 FAX (518) 458-5479

I wish to apply to the graduate certificate program in:

• SPECIAL EDUCATION: MIDDLE SCHOOL & ADOLESCENT LEVELS
• PROGRAM EVALUATION
• INSTRUCTIONAL TECHNOLOGY

Please include an application fee of $35.00 (check or money order payable to The College of Saint Rose) along with:

1. Statement of Purpose - a short (less than 300 words) description of your reason for choosing this certificate program.
2. Official transcripts from ALL colleges you have attended.
3. Two letters of recommendation.
4. Mail all application materials to: The College of Saint Rose, Office of Graduate and Continuing Education Admissions, 432 Western Avenue, Albany, NY 12203

Name: _____________________________________________________________

Address: ___________________________________________________________

___________________________________________________________________

Home Phone: ___________________ Work Phone: ___________________

Cell Phone: ___________________________

Email Address: _______________________________________________________

Date of Birth: ______/______/_____ Social Security Number: _______-_______-______

circle one: Gender: Male Female

Citizenship: ___________________________ City/Country of Birth: ___________________________

Optional: Ethnic Origin: Asian Indian/Native Alaskan _____ Black/Non-Hispanic ______
White/Non-Hispanic ______ Hispanic _____ Asian/Pacific Islander ______
Other: ____________________________

Colleges and Universities attended, including previous Saint Rose credits. Begin with your most recent enrollment.

Name of Institution Dates Attended Major Degree & Date Received

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Teaching Certification (s) held: Provisional/Initial ________ Permanent/Professional ________

Certification Areas: _____________________________________________________________________________

Place of Employment: _____________________________________________________________________________

Job Title: ______________________________________________
Date of Employment : ______/______/_____

Address of Employer: _____________________________________________________________________________

I certify that the information given in this application is complete and accurate.

Signature: ______________________________________________ Date: ______/______/______

To print a PDF version of the application, click here.